Corrective Action Plan: Medicaid and CHIP Eligibility The Ohio Department of Medicaid (ODM) agrees that accurate and timely eligibility determinations are essential to the integrity of the Medicaid program. Medicaid eligibility rules are complex. During the audit, AOS Auditors submit questions about...
Corrective Action Plan: Medicaid and CHIP Eligibility The Ohio Department of Medicaid (ODM) agrees that accurate and timely eligibility determinations are essential to the integrity of the Medicaid program. Medicaid eligibility rules are complex. During the audit, AOS Auditors submit questions about sampled cases to county departments (CDJFS) and to ODM for review. For future audits, the Department and the Auditor have agreed to meet before the audit concludes to review potential eligibility issues and ensure both teams understand the actions taken on each case. The Department does not agree with the finding that one of the sampled Medicaid recipients was improperly enrolled. In this case, the county agency did not receive reliable information about the individual’s income until October 2024—after the date the services were provided. The CDJFS discontinued services promptly once the information was reported. Under 42 CFR § 435.919, agencies must redetermine eligibility when they receive reliable information that may affect eligibility. Therefore, the individual was validly enrolled at the time services were received. The Department also disagrees with one CHIP-related finding where a child was placed in an incorrect aid category. The child was enrolled in the CHIP 1 category, while Auditors found the child was eligible for CHIP 2. Both categories provide the same federal match rate and the same benefits. The child remained eligible for Ohio’s CHIP program regardless of category. The administrative issues noted above are technical inaccuracies that require correction; however, they do not mean the individuals were ineligible for Medicaid. For example, if a CDJFS fails to upload employment documents into Ohio Benefits, this is a procedural error. If the person’s income still meets the program requirements, they remain eligible. It is important to emphasize that errors in documentation or processing do not necessarily mean ineligible individuals received benefits. Dates of Death and Ohio Medicaid The Department agrees with the Auditor’s concern about services being billed after an individual’s date of death. However, a portion of the 13,159 payments cited—totaling $2.5 million and covering 2,165 deceased individuals—were either allowable under policy or have already been recouped. For example, monthly rental charges for durable medical equipment (DME) may be billed after the date of death if the equipment was delivered earlier. Under OAC 5160-10-01(C)(16)(e), a monthly rental payment covers the entire month. If the Auditor’s sample reflects the larger population, roughly two-thirds of the payments identified were appropriate. Presenting the full $2.5 million without this context may be misleading to readers unfamiliar with common billing practices and applicable rules. The Department has been actively addressing the issues that lead to improper payments after the date of death throughout SFY 2025. The Department updated its use of death certificate data from the Ohio Department of Health (ODH), which required a revised data-use agreement and new automation. The updated interagency agreement took effect May 6, 2025, and a bot was deployed on July 25, 2025 to automatically verify dates of death and discontinue Medicaid coverage. This change shifts work away from county caseworkers, reduces system alerts, and prevents additional payments. The average delay between date of death and this automated update is now 57 days, compared to an average 142-day delay when relying on the federal master death file. This new approach both reduces workload and speeds up eligibility updates. The Department is also testing a process to automatically identify and recover fee-for-service (FFS) claims paid after the verified date of death. Providers will be notified of these claims so they can be reprocessed or recouped. While automation is being developed, ODM is also implementing a manual process to ensure recovery moves forward. Managed care capitation payments are already automatically recouped and are not part of this process. During the SFY 2025 audit, the Auditor did not identify any managed care capitation payments made for months after an individual's death, indicating that the corrective actions implemented are effective. For point-of-sale pharmacy claims, the Single Pharmacy Benefit Manager (SPBM) has implemented a review process to identify claims paid more than one day after a member's date of death. As of July 1, 2025, these claims are being reversed and recouped. Many such claims were the result of automatic prescription refills. To address this, ODM and the SPBM issued a memo to all Medicaid pharmacy providers on March 24, 2025, reminding them that automatic refills are not permitted for Ohio Medicaid members. Refills must be initiated by a prescriber, member, or authorized agent. Claims found to be automatic refills may be subject to recoupment. The Department will continue to verify recipient eligibility, ensure information in Ohio Benefits is accurate, and confirm that eligibility decisions are fully supported and completed on time. The Department’s Medicaid Eligibility Quality Control (MEQC) team conducts ongoing reviews of approved, denied, and discontinued cases to ensure accuracy. When the MEQC team identifies an error or technical issue, the responsible party must provide a root-cause analysis and corrective action plan. MEQC also partners with the Department’s County Technical Assistance and County Engagement teams to ensure training addresses recurring issues. The Department agrees with the Auditor’s recommendation to continue working with state and county agencies to strengthen processes, procedures, and system programming related to eligibility, including improvements to the Ohio Benefits system. The department meets with the Department of Job and Family Services and the Department of Children and Youth regularly to discuss policy changes, assess impacts, and identify alignment opportunities. All agencies also participate in system meetings to review issues, plan enhancements, and ensure updates do not negatively affect other programs. The Department will pursue full reimbursement of all claims improperly paid for services after an individual’s date of death. FFS claims have been referred to the Bureau of Program Integrity’s Surveillance Utilization Review Section (SURS) for review and recoupment. SPBM pharmacy claims will be reviewed and recouped through the established SPBM process. Anticipated Completion Date for Corrective Action: December 2026 Contact Person Responsible for Corrective Action: Name: Megan Powell Title: Audit Remediation Manager Address: 50 West Town Street, Suite 400, Columbus, Ohio 43215 Phone Number: 614-752-3844 E-Mail Address: megan.powell@medicaid.ohio.gov